Group Life Insurance Portability Kit Life insurance protection after group coverage ends LDM-6249 1/14
Don t leave your group life insurance behind. You know how important it is to own life insurance. That s probably why you signed up for it through your current employer in the first place. The good news is you can take it with you when you leave your job. Portability is a provision included with your company s group life insurance policy offered by Symetra Life Insurance Company. It allows you to continue coverage at your current group rates when you move on without having to answer any medical questions. Eligibility You are eligible for portability coverage as long as: 1 Your company s group life coverage includes the portability option. (Confirm with your employer). Your company s group life insurance policy, and the portability provision, remains in-force. You do not qualify for employee coverage under any other group life insurance policy. You haven t reached Social Security normal retirement age (SSNRA). You re not entering active military service. How portability works You can choose to continue 50%, 75% or 100% of your current life insurance benefit amount. Be sure to carefully consider all of your life insurance needs if you decide to port a reduced percentage of your current life insurance benefit amount today, you won t be able to continue any portion of the remaining amount at a later date. Portability may also be available for your spouse and dependents. If this provision is included in your company s policy, you can select portability coverage as long as they are insured under the current group life policy at the time your group coverage terminates. Child coverage may only be ported if you or your spouse elects portability. Whatever you choose, the benefit amount will be rounded to the next higher multiple of $1,000 (example: $125,100 rounds to $126,000) up to the maximum amount shown in the chart to the right. Maximum Amount Minimum Amount You $250,000 $5,000 Your spouse $50,000 $5,000 Your dependent child $10,000 $5,000 This chart represents standard benefit maximums. For more information on your company s policy, talk with your HR representative. Symetra Group Life Insurance Portability Kit
Frequently Asked Questions Do I need a medical exam? No. A medical exam is not required and you will not have to answer any health questions. How much does it cost? The actual cost (rate) is based on the amount of premium you are paying as of the date you are approved for portability. This amount will match the group rates for the first three years following the approval date. After three years, rates are reviewed annually and may change. My group life plan includes portability and conversion provisions. What s the difference? The primary difference is the type of insurance policy you receive. Provision Portability Policy Type Group Term Life Insurance. This type of policy provides protection for a limited period of time, typically at group rates which tend to be lower cost than other types of coverage. Coverage remains associated with the group life insurance policy that provided the right to port. If that coverage ends, the ported policy ends too. Once I m covered, will my benefit amount stay the same? Benefit amount reductions are the same as the group policy. Contact your HR representative for more information. Will I have life insurance coverage during the port period? Yes. Your group insurance benefits remain in effect during the 31-day transition to the ported policy. Can I convert to an individual policy if my coverage is reduced? Yes, if your benefit amount is reduced due to the age reduction schedule, you can convert your ported group policy to individual coverage. The cost is based on your age at the time you apply for conversion so choosing to port first and convert at a later date may impact the amount of premium you pay. Conversion Individual Permanent Life Insurance. This type of policy provides lifetime protection provided that sufficient premiums are paid. Pricing is based on individual rates which tend to be more expensive than a ported policy. This is an individual policy so the employee is the policyowner rather than the group. The policy also accumulates a cash value that can be borrowed against, if needed. Getting started To apply for portability, fill out Part A of the enclosed application. Your employer is responsible for completing Part B. Please don t delay. We need to receive your application and initial premium within 31 days from the date your group coverage ends. Send your completed application and initial premium to: Symetra Life Insurance Company PO Box 1491 Minneapolis, MN 55480-1491
Getting Started Don t miss the deadline. Complete your portability application today. For more information on how to port your coverage, talk with your HR representative. Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135 www.symetra.com Symetra is a registered service mark of Symetra Life Insurance Company. Group life insurance policies are insured by Symetra Life Insurance Company, 777 108th Ave NE, Suite 1200, Bellevue, WA 98004. Policy form number is LGC-13000 8/06 in most states and is not available in any U.S. territory. Our New York subsidiary insures products for New York policyholders. Policies contain exclusions, limitations, reduction of benefits and terms for keeping them in force. Please contact your group life representative for complete details. 1 Eligibility is verified on an annual basis.
Symetra Life Insurance Company 777 108th Avenue NE, Suite 1200 Bellevue, WA 98004-5135 Mailing Address: PO Box 1491 Minneapolis, MN 55480-1491 Phone 1-800-426-7784 TTY/TDD 1-800-833-6388 APPLICATION Portability Continuation of Group Term Life Insurance Part A: TO BE COMPLETED BY THE APPLICANT Submit your first premium with this application to Symetra Life Insurance Company at the above mailing address. IMPORTANT INFORMATION - The enrollment period ends 31 days from the date the Group coverage ends. The application, enrollment form(s), and premium sent to Symetra must be postmarked within this 31 day period. 1. Applicant s Name 2. Telephone No. Home ( ) Work ( ) Premium billing address for Life Insurance, if different than above: Address: 3. Birth Date Sex: Male Female 4. Policyholder Name Group Policy No. 5. Amount of Portability Continuation Basic Life Insurance $ Amount of Portability Continuation Supplemental Life Insurance $ Important: The minimum and maximum amounts of insurance for which You are eligible are shown in your Group Insurance Certificate. Refer to the Benefits section, Limitations provision, for specific information. Yes, I would like to continue my Spouse Life Insurance amount of $ Date of Birth Spouse Name Yes, I would like to continue my Child Life Insurance amount of $ Child Name Date of Birth Child Name Date of Birth 6. Premium Mode: Quarterly of $ Semi-Annual of $ Annual of $ In order to be eligible for Portability Continuation Insurance, you must submit your first premium with this application. Please make your check payable to Symetra Life Insurance Company. 7. Last day of active work with the employer providing the Group Policy 8. Are you disabled? No Yes If yes, date of disability: from to If yes, have you applied for Waiver of Premium? No Yes Please note: If you have applied for waiver of premium, you may not be eligible for Portability. Diagnosis I certify, under penalty of perjury, that the above information is correct to the best of my knowledge. Signature of Applicant Date Please have your employer complete Part B of this application LG-1156a 1/14 Page 1 of 4 Symetra is a registered service mark of Symetra Life Insurance Company.
Part B: TO BE COMPLETED BY THE EMPLOYER Instructions: Please fully complete this form and submit with ALL original enrollment cards and any requests for change of beneficiary. 1. Symetra Group Policy Number Policyholder Name Division of 2. Applicant s name 3. Date hired Effective date of applicant s life insurance 4. Insurance class Occupation 5. Current salary $ per hour week month year 6. Number of hours worked each week 7. Date employment terminated Last day of active work 8. Date Group Life Insurance would otherwise terminate under this policy for employee 9. Date through which premiums were paid for this employee 10. Is the applicant disabled? No Yes If yes, date of disability: from to 11. Reason for stopping work 12. At the time coverage terminated under this policy, the following amounts of Life Insurance available for Portability were in force for each of the following: a. applicant $ b. spouse $ c. children $ 13. Enrollment cards submitted? No Yes If no, please explain Important: Applicants who choose to convert their Group Life Insurance coverage to an individual policy upon termination of employment are not eligible for Portability Continuation Insurance. I hereby certify that the above individual was a full-time, permanent, active employee. I am not a beneficiary, nor am I related to the beneficiary or the above individual. I am an authorized employer representative and confirm the above statements are true. Name of Policyholder-Employer Phone No. ( ) Email FAX No. ( ) By Title Date Signature LG-1156a 1/14 Page 2 of 4
How to Compute Portability Continuation Insurance Premium Important: Premium modes other than annual are subject to a minimum premium payment of $50. Key: A. Group Rate per $1000 obtain from your employer B. Number of thousands the total number of 1000s of Insurance. Example: $10,000 of insurance is 10 thousands. C. Monthly premium is the cost of insurance each month. Premium for this coverage must be paid either quarterly, semi-annually or annually. D. See question 6 on the first page of this form. The premium for Portability Continuation Insurance is found by taking the: EMPLOYEE SPOUSE CHILD A. Group rate per $1000 $ B. Multiplied by the number of thousands C. Equals a monthly premium $ D. Multiply by the premium mode selected x 3 for quarterly $ x 6 for semiannual $ x 12 for annual $ A. Group rate per $1000 $ A. Group rate per $1000 $ B. Multiplied by the B. Multiplied by the number of thousands number of thousands C. Equals a monthly premium $ C. Equals a monthly premium $ D. Multiply by the premium mode selected D. Multiply by the premium mode selected x 3 for quarterly $ x 3 for quarterly $ x 6 for semiannual $ x 6 for semiannual $ x 12 for annual $ x 12 for annual $ Primary Insured Effective Date Symetra Life Insurance Company and the Insured agree as follows: Symetra Life Insurance Company will make payment to the most recently named beneficiary as shown below. Beneficiary Information (Print each name in full) Primary Name _ Relationship to Insured Percentage( % ) Name _ Relationship to Insured Percentage( % ) Contingent Name _ Relationship to Insured Percentage( % ) Name _ Relationship to Insured Percentage( % ) Primary Insured s signature Date LG-1156a 1/14 Page 3 of 4
CLAIM FORM FRAUD WARNINGS Please read the following notice that we are required by law to give to you. For all states not named: Any person who, with intent to defraud or knowing he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement may be guilty of insurance fraud. AL: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to restitution fines or confinement in prison, or any combination thereof. AR, LA, RI, WV: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. AZ: For your protection Arizona law requires the following statement to appear on this form. Any person who knowingly presents a false or fraudulent claim for payment of a loss is subject to criminal and civil penalties. CA: For your protection California law requires the following to appear hereon: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of regulatory agencies. DE: Any person who knowingly, and with intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony. DC: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant. FL: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony of the third degree. ME: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits. MD: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison. NH: Any person who, with a purpose to injure, defraud, or deceive any insurance company, files a statement of claim containing any false, incomplete, or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20. NJ: Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties. Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties. NM: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties. NY: The following applies to health insurance only: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation. OK: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony. PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. TN, VA, WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits. TX: Any person who knowingly presents a false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison. LG-1156a 1/14 Page 4 of 4